There are currently no gold standards for the documentation of orbitofacial fractures. In 2012, a regional trauma centre audit found locally recommended documentation to be lacking. A trauma pro forma was introduced, multidisciplinary meetings established and a more robust referral system created between maxillofacial and ophthalmology departments. This audit reviewed if documentation had improved since the introduction of these changes.

Of 65 orbitofacial fracture patients presenting to A&E between 02/2012–04/2013, 43 files were located. Locally recommended documentation criteria at baseline and 2 weeks post-operative included: subjective symptoms, visual acuity, colour vision, swelling, conjunctival assessment, lid position, globe position, enophthalmos, extra ocular movements, pain on extra ocular movement, watering and diplopia. Six-month documentation criteria included enophthalmos and diplopia alone. Surgical patients achieved 100% compliance if they fulfilled all 26-point criteria. Non-surgical patients required only 14-points.

On average, surgical patients completed 9 out of 26-point criteria (34.6%). Non-surgical patients averaged 6 out of 14-points (42.9%). Nineteen patients did not attend one or more appointments and 8 patients were discharged by 4 months. Weak documentation included: watering, lid position, globe position and pain on extra ocular movement. Strong documentation included: visual acuity, extra ocular movements and diplopia

Overall documentation was found to be lacking. We propose a gold standard of 26-point (surgical) and 14-point (non-surgical) criteria. We will introduce a patient “orbital trauma” pathway booklet including these gold standards and re-audit in April-July 2014